Managing common vulvar skin conditions

The vulva is subject to a range of skin problems, many of them inadvertently self-inflicted.

You may routinely pamper your face and work hard to keep it moisturized and irritation-free, but what have you done lately for the more sensitive skin of your vulva, the external genital area surrounding your vagina?

Many women have been primed to think no further than "itch equals yeast infection." But with age and the decline in estrogen after menopause, we become more prone to a variety of conditions that irritate vulvar skin. These conditions aren't getting the medical attention they need -- and women aren't getting the relief they deserve.

"The differential diagnosis of vulvar problems is as complicated as for headache, chest pain, or diarrhea. There are many, many causes," says Elizabeth G. Stewart, M.D., assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School and director of the vulvovaginal service at Harvard Vanguard Medical Associates.

Anatomy of the vulva

The vulva (Latin for womb or covering) consists of several layers that cover and protect the sexual organs and urinary opening. The fleshy outer lips of the vulva -- the labia majora -- are covered with pubic hair and contain fat that helps cushion the area. Inside the labia majora are the thinner, more pigmented and delicate flaps of skin called the labia minora. The labia minora join at the top to enclose the clitoris. The labia majora, labia minora, and clitoris are made up of erectile tissue, that is, tissue that can become engorged with blood. The area between the labia minora, the vestibule, contains the openings to the urethra and the vagina, as well as the Bartholin's glands, which are located on either side of the vaginal opening and produce lubricant for the vestibule. The flesh between the vaginal opening and the anus (not part of the vulva but often involved in vulvar skin problems) is the perineum. This is where the incision called an episiotomy is sometimes made during childbirth.

Getting a diagnosis

Vulvar skin conditions are highly treatable, but the treatment depends on the specific cause. Few physicians specialize in vulvar problems, and few medical schools provide much training in this field. If your primary care physician can't help, call the gynecology or dermatology department of the nearest teaching hospital and ask for a recommendation. There may be a vulvar clinic nearby -- or a gynecologist or dermatologist with a particular interest in such problems or long experience in dealing with them.

Tell your clinician about any other past or present medical conditions (including bladder and bowel issues) and any skin problems elsewhere on your body. For example, psoriasis anywhere on the body raises the risk of a vulvar condition known as lichen sclerosus. (This condition and others are described, below, in "Vulvar conditions and their treatment.") Crohn's disease, a chronic inflammatory intestinal disease, may cause abscesses or draining fistulas in the vulvar area, and vulvar skin problems are often one of its early symptoms. A mouth condition called lichen planus is another cause of vulvovaginal problems. (The term "lichen," as applied to skin disorders, refers fancifully to skin lesions that resemble lichen on rocks.) Long-term treatment with oral steroids, immune suppressants, or antibiotics also raises the risk for vulvar skin infection.

Your clinician will want to know how you care for your vulvar skin, which can help identify possible sources of irritation. Even if you can't pinpoint a change, that doesn't mean your standard routine isn't the culprit. Sometimes vulvar problems are the cumulative effect of long-term practices.

"It's often what you've done day after day, year after year, that causes the problem," says Dr. Stewart. "If you wear abrasive clothing and engage in abrasive activities like bicycling or spinning class and wear tight workout clothes that expose your vulva to sweat or to detergent or soap residue, eventually it might catch up with you."

Report all the symptoms that concern you, including itching, burning, soreness, discharge, bumps, and rashes. It will also help if you can provide a history of your symptoms and recall what seems to make them better or worse. Your clinician will examine the vulva, perhaps using a magnifying glass, and insert a speculum to inspect the vagina. She or he may test the pH (acid-base balance) of the vagina and take samples of secretions to examine under the microscope or culture for yeast. Remember, even if you're seeing an experienced clinician, several visits may be needed to diagnose and improve certain vulvovaginal conditions.

The problem with self-treatment

When vaginal or vulvar itching occurs, women usually assume it's a yeast infection and treat it with an over-the-counter antifungal cream. Often this does the trick, but not always. Of 153 women with recurring complaints who were evaluated for presumed yeast infections at the Vulvar and Vaginal Disease Clinic at Missouri's St. Louis University, only 40 had the common yeast, Candida albicans. In more than two-thirds of the women, the cause of the symptoms was dry skin, a sexually transmitted disease or bacterial infection, a less common strain of yeast that required special medication, or irritation by and allergic reactions to common products such as soaps, creams, and lotions.

If yeast isn't the problem, an antifungal cream isn't the solution. And if your skin is already irritated, you may exacerbate the problem by introducing preservatives (such as alcohol or propylene glycol) and other ingredients contained in many antifungal remedies. That's why it's important to see your gynecologist or dermatologist if a problem persists after you've tried a standard antifungal cream.

Another common response of women faced with a vaginal discharge or itch is to wash the vulvar skin vigorously, on the assumption that this will disinfect the area or remove irritants. But aggressive cleansing can add to the irritation. Until the problem is diagnosed, it's best to follow a gentle skin care routine (see "Gentle vulvar care"). In fact, gentle cleansing applies whether you have a vulvar skin condition or not: Wash the area gently with your fingertips or a soft cloth and pat dry with a soft towel. Don't use a rough washcloth, and don't rub.

Possible vulvar biopsy

Particularly if initial treatment hasn't eased your symptoms, the clinician may need to take a small tissue sample (biopsy) to make a diagnosis. Specialists say that vulvar biopsies are underused. The procedure, which is minor and done under local anesthesia, is extremely valuable, often changing the diagnosis and treatment plan. In May 2008, researchers from the University of Utah reported on the results of 89 vulvar biopsies in women who had been treated for a variety of conditions causing vulvar pain. In 61% of the women, biopsies revealed a previously undiagnosed disease of the skin or mucous membranes of the vulva.

The Utah study provided another important finding: among the 20 biopsies read first by a general pathologist, seven diagnoses were changed after the tissue was re-examined by a dermatopathologist -- a pathologist specializing in skin disorders.

"Dermatopathologists have more experience looking at inflammatory skin conditions. If you get a nonspecific diagnosis from a general pathologist, you can ask to have the tissue re-read by a dermatopathologist," says lead author Anneli R. Bowen, M.D., assistant professor of dermatology at the University of Utah.